The first liposuction procedure was performed by a French physician in the 1920’s who, working with a thin metal tube attached to a suction device, believed it could be used to remove fat. It worked, but it was imprecise and bloody. The technique has been refined since then with improved anesthesia, less blood loss, and the use of tumescent fluid (salt water and some medicine injected into the fat before removal) to allow greater volumes of fat removal (1982). This was the beginning of the liposuction era.
Liposuction quickly became the most popular plastic surgery procedure performed by cosmetic surgeons. Surgeons experimented with greater and greater amounts of fat removal, trying to establish how much fat could be safely removed. In the best of hands, the procedure proved reliable, consistent and safe with high patient satisfaction.
Unfortunately, there were several reported cases of complications resulting after liposuction that made it clear that the procedure is associated with real risk. The procedure found its way into the hands of unqualified practitioners who, with the inadequate use of anesthesia, performed liposuction in unsafe environments. Interest in the procedure remained high, but concern about anesthesia and the qualifications of the practitioners created fear among those considering liposuction.
To maintain interest and demand for the procedure, marketers worked their magic by promoting the idea that conventional anesthesia was not needed, and that new devices improved the outcomes. These newer techniques included the use of ultrasonic liposuction, power assisted liposuction, laser liposuction and even the “freezing” of fat as a “non-invasive” technique that requires no surgery at all. Imagine having liposuction during your lunch break and having your fat melted away magically! Smart naming of particular devices was designed to make them sound easy, safe and effortless — think about the name “SmartLipo.”
In the early 2000’s the market for liposuction moved to accommodate fancily named devices and the use of local anesthesia. Greater and greater numbers of non-plastic surgeons started to provide liposuction in their practices as a way to supplement their incomes in a hostile insurance environment (it was difficult for many medical providers to make a living practicing in their trained specialty). Inevitably, the quality of the outcomes suffered: liposuction was done in a “patchwork” fashion because of the limitations of not having adequate anesthesia, and the standards for selecting the proper patient were lowered because of the need to pay for the expensive machines unqualified practitioners had purchased.
Fast forward to the year 2017. Liposuction is still performed in a similar manner as it has been since the 1980’s. A tube is inserted under the skin and fat is contoured. A myriad of machines and names are available to practitioners but no individual technique has proven better than any other. Research in the field of liposuction has focused on the “non-invasive” application of energy systems to contour fat, during which no probe is inserted into the skin. None of the current “non-invasive” techniques offer anything but the most minimal improvements in the appearance of fat deposits relative to traditional method.
After many years of all types of practitioners engaging in one of the most requested procedures, it basically has come full circle back to a form of traditional liposuction. The power machines have proven to be too powerful with the end result being significant contour irregularities and scarification of the tissues. It simply isn’t gentle enough or refined enough compared to traditional liposuction. We have become more conservative in the contouring of body fat because the results are better, more natural and without the potential for complications and irregularities.
An important consideration for liposuction continues to be the patient’s BMI (Body Mass Index) which relates height to weight. The most appropriate patients for liposuction are those who are close to or at their ideal BMI. The most important thing is for you to not be overweight when you are considering liposuction.
In experienced hands, liposuction is a routine, reliable procedure with high patient satisfaction, few complications and a high safety profile. Small volume fat removal require minimal anesthesia while larger volume, multiple area treatment requires the services of an Anesthesiologist for your comfort and safety. Large volume liposuction (the removal of more than 5 liters of fluid and fat) should only be performed by an experienced plastic surgeon. The concept of skin tightening is a complete exaggeration of the truth and is nothing you would ever see or feel. Ultimately, safe liposuction with impressive results is dependent on the experience and skill of your surgeon.
Liposuction is ideal for patients who are at or close to their ideal body weights, have thick elastic skin and have limited areas of fat deposits (lipodystrophy). Patients who are overweight and who have experienced large weight swings over the years place themselves at risk for the actual procedure and may face long-term disappointment. Liposuction is not a “quick fix” or “jump start” to managing obesity or weight fluctuations. Visiting a plastic surgeon at the height of your weight is not a good idea.
Some patients who have had previous liposuction can find themselves looking odd and unbalanced in the years that follow, as any weight gained will “travel” to untreated areas faster than to treated areas. This is the long-term risk associated with liposuction and can only be avoided if patients maintain their healthy and ideal weight throughout their lives. Experience has taught us all that as we get older, we often put on weight, so patients must be aware of this reality and be very careful when considering liposuction. This is a critical point that every reliable surgeon should discuss with you during a consultation.
Liposuction should be performed in an appropriate operating environment. Some form of anesthesia is necessary and desirable in all but the smallest cases. The areas to be treated are first filled with saline solution and then a probe or device is inserted into the fat and maneuvered to contour the fat. Small, strategic incisions are made to allow for the insertion of the cannula without scarring.
The surgeon will contour the fat to the best of his/her ability so that the result is symmetrical and appropriate for the individual patient. After the procedure is completed, the patient must wear a compression garment for weeks afterwards. Liposuction is generally performed as an outpatient procedure.
This depends on the practitioner. A few small areas can be treated with tumescent anesthesia only. This means that fluid is placed into the fat that gradually numbs it, after which time the surgeon will contour the fat. Additional oral or IV anesthesia can be used to dull the pain, discomfort or anxiety associated with an awake patient.
Full anesthesia requires the presence of an anesthesiologist who will ensure that you will not have any pain or discomfort during the entire procedure. This is best for those patients who have multiple areas, are sensitive to pain, have a lot of anxiety or “don’t want to be aware of the surgery.” It is quite difficult to obtain even anesthesia when using the tumescent technique alone and it is very common for you to feel considerable pain and discomfort during the actual procedure. Precise sculpting of the fat is a challenge in any moving patient experiencing pain.
Recovery from liposuction is directly related to the amount of fat removed and the number of areas treated. Treating only the abdomen, for example, will be less painful than simultaneous treatment of multiple areas. Large volume liposuction procedures often require about 5 days of recovery, whereas treatment of only the abdomen requires 1 or 2 days at most. Soreness is associated with smaller areas while pain and discomfort are associated with larger area treatment.
Immediately after the procedure, the patient wears a compression garment. Some watery or bloody draining from the incision sites should be expected, but this will stop after about 12 hours. The patient is instructed to move around daily, but avoid exercise for about a week or longer depending on the amount of fat removed. Patients are instructed to start using a dough roller on the treated areas after a week or two to ensure a smooth result. A machine designed to help with cellulite, called Endermology, works very well after liposuction to control swelling, promote skin retraction and ensure a smooth result.
Movement after liposuction actually helps you heal, reduce pain and stiffness and recover more quickly. If your lower extremities have been treated, make sure that you keep them elevated above your heart.
The skin of the body is quite different in the various regions of the body. For instance, back skin is quite thick while skin of the upper medial thighs and posterior arms is quite thin. The surgeon must use greater care when performing liposuction of the abdomen, upper medial thighs, face, neck and posterior arms. In inexperienced hands, these areas are more prone for contour irregularities. Liposuction of the face should only be performed by an experienced surgeon and only on carefully selected patients. The results of any liposuction depend very much not only on the amount of fat removed, but also on the amount of fat that remains after treatment; removal of too much fat will almost certainly result in collapse of the skin and severe, often uncorrectable skin deformities.
There is an immediate improvement in the size and contour of your body after liposuction. Swelling is most obvious the first few days and improves dramatically with time. The compression garment should be worn for about four to six weeks. It may seem initially bothersome, but most patients find it very supportive and comfortable once they get used to it. Use of the dough roller for skin massage is very helpful for controlling swelling. Bruising is common after liposuction and may persist for a week or longer. By six months, most discomfort is gone.
Liposuction can be used as a “motivator” in very carefully selected patients who have the psychological profile and appropriate support systems in place for success.
There is no problem with more than one liposuction as long as it is not a result of weight gain and a request for more fat removal. I am often asked to perform “secondary” liposuction on patients who previously had inexpert and asymmetrical liposuction. It is actually quite rare that patients who seek out liposuction have only one or two areas that need contouring. Most patients have multiple areas that require treatment to obtain the best result.
After choosing the most qualified and experienced surgeon, the quality of your skin is the primary determinant of the result you obtain. Patients with thick, elastic skin will experience better skin retraction with fewer contour irregularities after liposuction. Those with older skin, cellulite and general skin laxity will almost certainly experience lax skin and irregularities afterwards no matter what technique is used. In fact, the marketing of “skin tightening” liposuction techniques was to perpetuate a myth that your skin will retract more than with other techniques—this is simply not the case.
Unhealthy patients should not consider liposuction, nor should overweight patients.
Move after liposuction, exercise good posture, use the compression garment and roller device and spend the money on Endermology if you can.
Serious complications are uncommon with liposuction. All patients will bruise to some degree, which can last up to 10 days. Numbness of the skin is common early on and is most noticeable around the knees and lower back. Swelling of the skin is universal in treated areas. The lower extremities will swell more and last longer because of their dependent position.
Bleeding and infection are quite uncommon after liposuction. A seroma or fluid collection can occur almost anywhere but are more common on the abdomen and in larger volume liposuction. Contour irregularities can occur when liposuction is done inexpertly or if the patient has poor skin elasticity. It is more likely on the abdomen, posterior arms and upper medial thighs. Asymmetry and disproportional results can result from poor technique, inadequate anesthesia and poor patient selection.
Perhaps the greatest risk associated with liposuction is underestimating the gravity of the procedure and electing to have your liposuction done by unqualified practitioners and not having adequate anesthesia. You should not consider liposuction if you are overweight and have an unstable weight history.
— Robert Caridi, M.D.
Certified Plastic Surgeon
Founder of Westlake Plastic Surgery
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